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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010083
Report Date: 03/20/2024
Date Signed: 03/20/2024 05:53:46 PM

Document Has Been Signed on 03/20/2024 05:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ACHIEVERSFACILITY NUMBER:
493010083
ADMINISTRATOR:HEATHER PETERSFACILITY TYPE:
850
ADDRESS:573 SUMMERFIELD ROADTELEPHONE:
(707) 539-6232
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 90TOTAL ENROLLED CHILDREN: 55CENSUS: 36DATE:
03/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Heather PetersTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Strother arrived unannounced to the facility at 1:50pm. LPA was greeted by Staff (S1) who stated that the Center Director, Heather Peters (D1) was currently away from the facility on a lunch break. Also present at the facility were 4 additional staff, Staff 2 - Staff 5 (S2-S5). LPA reviewed the Employer Roster printed from Guardian on 03/19/24. The Employee Roster is a list of the individuals that have criminal record clearances associated to the facility. LPA did not see staff S4 or S5 listed on the roster. S1 stated that it was S4's first day of employment and that S5 had worked at the facility for awhile. When D1 arrived back to the facility she stated that she had confirmed with the Licensing Regional Office in Santa Rosa that S4 and S5 had eligible clearances prior to beginning employment and sent copies of S4 and S5's driver's licenses to the Licensee of the facility who is responsible for transferring the fingerprints in Guardian. LPA reviewed Guardian during the visit, verifying that although S4 and S5 did have eligible criminal record clearances, they had not been associated to the facility. LPA made both D1 and Licensee (L1) aware of the deficiency. L1 stated during a phone call with LPA Strother that she would take care of it and associate S4 and S5 to the facility right away. At 4:52pm L1 emailed LPA Strother verification that she had in fact associated S4 and S5 to the facility.

The following violation of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Exit interview conducted and report was reviewed with facility representative, Heather Peters.

A notice of site visit was given to facility representative and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/20/2024 05:53 PM - It Cannot Be Edited


Created By: Amy Strother On 03/20/2024 at 05:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ACHIEVERS
FACILITY NUMBER: 493010083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2024
Section Cited
CCR
101170(e)(2)

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101170(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)

This requirement is not met as evidenced by:
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Licensee associated S4 and S5 to the facility and sent proof to LPA during the visit. Director stated that she and the Licensee will create a written procedure for associating employee fingerprint clearances to the facility, including how to verify that it has been completed, sending the written procedure to LPA Strother by 03/27/24. amy.strother@dss.ca.gov
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Based on observation, record review, and interview the licensee did not associate 2 of 6 staff criminal record clearances to the facility. S4 and S5’s criminal record clearances were not transferred to the facility prior to the first day of employment, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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